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  1. Surveys
  2. 2012
  3. August
  4. B
  5. Behavioral Outcomes
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How much physical activity do you do in a day?
 
20 minutes
 
30 minutes or more
 
less than 20 minutes
 
none
 
 
 
Comments/Suggestions: Briefly describe a normal day in your life from morning to night.
   
 
 
 
What foods do you eat on a regular basis?
 
Fast Food
 
Snack Food
 
Fruits/vegetables
 
Meats/dairy
 
Breads/pasta
 
 
How would you rate your lifestyle in terms of physical activity.
Once a week twice a week three times a week four times a week five times a week more than five times a week
Sedentary
Active
Some activity
 
 
 
From the flowing pick out what would be the best food choice.
 
Potato chips
 
Fries
 
Wheat pasta
 
Mashed potatoes
 
 
 
Briefly explain why you selected the above answer.
   
Comments/Suggestions:
   
 
 
How do you feel about the understanding of your family health hsitory:
Very knowledgeable Slightly Knowledgeable Neutral Not Knowledgeable
Parents
Grandparents
Overall
 
 
If you have knowledge about your family health history rate your health risks?
1 2 3 4 5
Heart Disease
Diabetes
obese/overweight
Cancer
 
 
How satisfied are you with your personal diet in terms of it being healthy?
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied
Breakfast
Lunch
Dinner
Snacks
 
 
 
Comments/Suggestions: For the above choices list one thing you consume for each meal.
   
 
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